Physical Problems and Complications in the Puerperium

Chapter 25 Physical Problems and Complications in the Puerperium



The need for women-centred and women-led postpartum care


The woman’s social and ethnic environment should take into account their individual perceptions and experiences surrounding the pregnancy and the birth event. Where the birth involved complications, postpartum care is likely to differ from that of women whose pregnancy and labour are considered straightforward; the role of the midwife in these cases is:



image to identify whether a potentially pathological condition exists


image if so, to refer the woman for appropriate investigations and care.



Immediate untoward events for the mother following the birth of the baby



Postpartum haemorrhage




image Immediate (primary) postpartum haemorrhage (PPH). This is the most immediate and potentially life-threatening event occurring at the point, or within 24 hours, of delivery of the placenta and membranes. It presents as a sudden and excessive vaginal blood loss of 500 ml or more. (See Ch. 19 for management.)


image Secondary or delayed PPH. This is where there is excessive or prolonged vaginal loss from 24 hours after delivery of the placenta and for up to 12 weeks postpartum. Unlike primary PPH, which includes a specified volume of blood loss as part of its definition, there is no such volume defined for secondary PPH.


Regardless of the timing of any haemorrhage, it is most frequently the placental site that is the source. Alternatively, a cervical or deep vaginal wall tear or trauma to the perineum might be the cause in women who have recently given birth. Retained placental fragments or other products of conception are likely to inhibit the process of involution, or reopen the placental wound. The diagnosis is likely to be determined by the woman’s condition and pattern of events and is also often complicated by the presence of infection (see Box 25.1).



Box 25.1 Secondary PPH



Signs of secondary PPH




• Lochial loss is heavier than normal


• Lochia returns to a bright red loss and may be offensive


• Subinvolution of the uterus


• Pyrexia and tachycardia


• Haematoma formation



Treatment




• Call a doctor


• Reassure the woman and her support person(s)


• Rub up a contraction by massaging the uterus if it is still palpable


• Express any clots


• Encourage the mother to empty her bladder


• Give an uterotonic drug, such as ergometrine maleate, by the intravenous or intramuscular route


• Keep all pads and linen to assess the volume of blood lost


• Antibiotics may be prescribed


• If retained products of conception are seen on an ultrasound scan, it may be appropriate to transfer the woman to hospital and prepare her for theatre



Maternal collapse within 24 hours of the birth without overt bleeding


Consider:



image inversion of the uterus


image amniotic fluid embolism


image cerebrovascular accident.



Postpartum complications and identifying deviations from the normal


The midwife needs to establish whether there are any signs of possible morbidity and determine whether these might indicate the need for referral. Figure 25.1 suggests a model for linking together key observations that suggest potential risk of, or actual, morbidity.


image

Fig. 25.1: Diagrammatic demonstration of the relationship between deviation from normal physiology and potential morbidity.


The central point, as with any personal contact, is the midwife’s initial review of the woman’s appearance, psychological state and vital signs.



image A rise in temperature above 37.8°C is usually considered to be of clinical significance. A mildly raised temperature may be related to normal physiological hormonal responses: e.g. the increasing production of breast milk.


image A weak and rapid pulse rate in a woman who is in a state of collapse with signs of shock and a low blood pressure, but no evidence of vaginal haemorrhage, may indicate the formation of a haematoma. A rapid pulse rate in an otherwise well woman might suggest that she is anaemic but could also indicate increased thyroid or other dysfunctional hormonal activity.


image The midwife needs to be alert to any possible relationship between the observations overall and their potential cause, keeping common illnesses in mind – e.g. the woman may have a common cold.



The uterus and vaginal loss following vaginal birth


Assessment of uterine involution is needed where the woman:



image is feeling generally unwell


image has abdominal pain


image has a vaginal loss that is markedly brighter red or heavier than previously


image is passing clots


image reports her vaginal loss to be offensive.


Where palpation of the uterus identifies deviation to one side, this might be the result of a full bladder. Where the woman had emptied her bladder prior to palpation, the presence of urinary retention must be considered. Catheterisation of the bladder in these circumstances is indicated for two reasons: to remove any obstacle that is preventing the process of involution taking place and to provide relief to the bladder itself. If deviation is not the result of a full bladder, further investigations need to be undertaken to determine the cause.


Morbidity might be suspected where the uterus:



image fails to follow the expected progressive reduction in size


image feels wide or ‘boggy’ on palpation


image is less well contracted than expected.


This might be described as subinvolution of the uterus, which can indicate postpartum infection, or the presence of retained products of the placenta or membranes, or both.


Treatment involves:



image antibiotics


image oxytocic drugs


image hormonal preparations


or



image evacuation of the uterus (ERPC).



Vulnerability to infection: potential causes and prevention


Causes include:



image poor immunity


image pre-existing resistance to the invading organism


image virulence of the organism


image presence of hospital ‘superbugs’.

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Related posts:

  1. The Placenta
  2. Prolonged Pregnancy and Disorders of Uterine Action
  3. Obstetric Emergencies
  4. Problems of Pregnancy

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Jul 11, 2016 | Posted by in MIDWIFERY | Comments Off on Physical Problems and Complications in the Puerperium

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